Long-Term Impact of a Medical School Course on the Intersection of Art and Medical History

Background One recent trend in medical education is the integration of humanities into the curriculum, including viewing works of art in museums, with analysis of short-term, but not long-term, impact. We developed a course for medical students, trainees, and faculty at the Icahn School of Medicine at Mount Sinai co-taught by an art historian and a physician/medical historian that features images of great works of art to make connections between art and medical history with the following goals: 1. To encourage the students to make careful and systematic observations, describe what they see to others in the group, and exchange their views respectfully, 2. To sensitize students to the patient’s experience of illness by discussing artists’ depictions of patients and the impact of their illness on family and friends, and 3. To highlight milestones in medical history by focusing on artworks that epitomize the state of medical care and science at a defined point in time. We have taught the course for more than a decade and so wanted to assess whether participating in the course had a long-term impact. Methods We created and deployed a five-question survey to 167 students and received responses from 35 of those students. Results 97% of respondents answered that they still think about the course, and large majorities of the respondents indicated that the course, had an impact on how they viewed works of art (91%), their appreciation of the history of medicine (89%), and their observational skills (80%). More than half the students responded that the course sensitized them to the patient’s perspective of illness (63%) and had an impact on how they viewed their role as a physician (51%). Conclusions Our course has had a long-term impact on the respondents across a wide range of professional and personal characteristics.


Introduction
One of the major trends in medical education over the past two decades is the increasing integration of the humanities into the curriculum.Literature, music, and art have all been used to complement the intense scientific curriculum with the dual goals of developing important skills and providing a broad social context for understanding the role of the physician in society.Underlying these initiatives is the hope that these experiences will enhance the student's compassion, empathy, and commitment to social justice [1][2][3][4][5][6][7] .
One of the more popular methods of melding the disciplines of humanities and medicine has been the introduction of works of art into the curriculum via visits to local museums in order to sharpen students' observational skills, their ability to describe what they see, their ability to constructively exchange views with others in a group, and their ability to tolerate the uncertainty that is intrinsic to interpreting works of art.In these programs, works of art have primarily been chosen because they were available in the museum and because they depicted images that would facilitate achieving the objectives.The art historical context of the works is generally not considered or is incidentally introduced at the end of the session.Similarly, neither the medical historical significance nor connections to current medical practice of the work are generally considered.
A modest body of evidence has already been accumulated linking art observation training with attainment of some of these goals [8][9][10][11][12][13][14][15][16] .Dalia et al. performed a scoping review of the literature on published studies of the incorporation of art in the medical school and resident curricula 17 .They narrowed their review to 28 studies in which the methodology was described and in which there was a postintervention assessment.They found wide variations in the structures of the programs and the assessment methodologies, and they concluded that incorporating art into medical education appears to improve visual perception skills, empathy, and personal reflection.They called for additional studies to define the optimum point of intervention during medical education, as well as follow-up studies to assess whether positive effects are lasting.
We sought to build on these programs by integrating our expertise in art history, in the history of medicine, and in medical education, by creating a course for medical students, postgraduate medical trainees, and faculty members based on in-depth discussions of works of art with importance in both art and medical history, as well as of works that would stimulate discussions of issues related to medicine and society.We created a series of seven sessions on a variety of topics (Table 1) that are co-taught by B.G.C. and B.S.C. and we host guest lectures on a variety of related topics at the Icahn School of Medicine at Mount Sinai (ISMMS).The course also includes two visits to the Solomon R. Guggenheim Museum to view works from the permanent collection and current exhibits, and a visit to the Rare Book Reading Room of the New York Academy of Medicine to view great books in the history of medicine, geared to the course and the students' interests extending back to the 16 th century.The visit to the New York Academy of Medicine is the final session each semester since the students invariably have a sense of awe seeing the authentic works we have discussed and placing them all in a historical context.We have taught the course each year since 2009, with the exception of 2020 because of the COVID-19 pandemic.
We set three primary goals: 1.To encourage the students to make careful and systematic observations, to describe what they see to others in the group, and to exchange their views respectfully, 2. To sensitize the students to the patient's experience of illness by viewing and discussing artists' depictions of sick individuals and the impact of their illness on those close to them, and 3. To highlight milestones in the broad sweep of medical history by focusing on artworks that epitomize the state of medical care and science at a defined point in time.Together, these lead to discussions of medical ethics and human compassion.Since we have been teaching the course for more than a decade to both students and faculty, and there is a gap in our understanding of any long-term effects of participating, we decided to assess whether participating in the course had a lasting impact as judged by responses to a survey focused on our primary goals.
Course description: The course is an elective in the ISMMS Academy for Medicine & the Humanities.It is offered in the fall semester as a series of weekly 90-minute sessions from September to December.Table 1 contains a list of the major components of the course, which includes: a series of sessions that two of us (B.G.C. and B.S.C.) jointly teach, guest lectures selected from those listed, visits to the Guggenheim Museum, which are led by members of the museum's educational staff, and the final session at the New York Academy of Medicine Rare Book Reading Room led by the Rare Book librarian.
To provide a sense of the sessions that are co-taught by two of the authors, we provide descriptions of three of the sessions in Supplementary Materials covering the topics of Observation in Medicine and Art; Skin Deep: Dermatology and Art; and The Gross Clinic and the Ascendancy of American Science and Medicine in the 19th Century.

Methods
This study was conducted under a protocol approved by the Institutional Review Board of the ISMMS (STUDY-20-01333) approved on February 2, 2021.Data collection began on July 9, 2021.All participants gave written informed consent to participate and were given the option of allowing or not allowing in writing each of their comments to be quoted anonymously.
Survey composition.The survey is reproduced in Table 2 and consists of questions to first determine: 1. whether the student took the course during the first five years or the second five years it was offered, and 2. whether they were a medical student, faculty member, or in another category when they took the course.This is followed by six yes/no questions related to: whether the students continue to think about the course; whether the course had an impact on their observational skills, how they view their role as a physician, how they view works of art, or their appreciation of the history of medicine; and finally,  whether they felt that the course sensitized them to the patient's perspective of illness.Students who answered yes to any of the questions were given an opportunity to add free text explaining their answer.If they entered any free text, they were then asked whether they gave permission for the text to be quoted anonymously in a publication.Survey deployment.We used the email addresses we had for the students when they took the course, augmented by contact information available from the ISMMS Office of Alumni Affairs.Together, this totaled 167 students, although not all participated in the entire course.Each student was sent an email signed by B.G.C. and B.S.C. inviting them to participate.Three additional email reminders were sent over the next year.Students who proceeded from the email to the survey were told the survey was anonymous.They were then asked if they gave their consent to participate, and if they did, they were given the survey to complete online.Their anonymous responses were entered into the Excel file.

Data analysis
This was a descriptive study and thus the data were collected in a spreadsheet and the numbers of individuals who provided each response counted and recorded.These were converted into percentages of the entire group.

Results
Survey responses: A total of 35 students provided completed surveys, and one student provided an incomplete survey that was excluded from the analysis.Table 3 presents the survey data, organized based on whether the student took the course during the first five years or the second five years it was offered, and whether the student was a medical student, physician, or in an Other category.Fifteen respondents were medical students when they took the course, 12 were ISMMS faculty members, and eight were in the Other category; the latter included two ISMMS non-physician staff members, one resident, one fellow, two physicians in other advanced postgraduate training programs, and two practicing physicians not affiliated with ISMMS.For ease of analysis, the Faculty and Other categories were combined into a single Physicians/Others category.
Global analysis: 97% (34/35) of respondents answered that they still think about the course.80% or more of the respondents indicated that the course had an impact on how they viewed works of art (32/35; 91%), their appreciation of the history of medicine (31/35; 89%), and their observational skills (28/35; 80%).Smaller percentages, but still more than half the students responded that the course sensitized them to the patient's perspective of illness (22/35; 63%) or had an impact on how they viewed their role as a physician (18/35; 51%).Table 4A-Table 4E contain selected free text comments made in response to each of the questions, categorized based on whether they were made by medical students or Physicians/Others.

Subgroup analyses:
Comparing medical students to Physicians/ Others: A total of 15 responses were from individuals who were medical students when they took the course compared to 20 who were in the Physician/Others group.Four of those in the medical student group took the course before 2016 and 11 took it after, compared with 12 and 8, respectively, in the Physicians/Others category.

Medical Students
[T]alking about art, when friends ask about the highlights of med school, when I talk to patients.
When I visit art museums or exhibits, I often consider the work through a medical lens, which is something I never did before.
Physicians/Others Thinking about how medicine and health is portrayed in art, specifically when I am at art museums.
Whenever I bemoan the fact that the current education of our students is so narrow in its vision.
Any time I think of medical history.Which is often.
[W]henever I saw arts in hospital, especially during the moment I visited the ether dome at MGH.
Whenever I am searching for art images, I remember Bobbi's detailed, comprehensive approach to a painting.I had never taken an art course previously and Bobbi's thorough approach of asking questions, i.e., dissecting a painting, as it were, while observing, is a fascinating one.

Medical Students
The course left in me an eagerness to ask questions about the things that we see -to pause and think about what is beyond the surface, and that is skill I will always carry with me.
I think the approach to patients -considering how one may read an encounter as one reads a painting -was quite valuable.
Yes, I feel as though this course helped me conceptualize medical observation as an art rather than as just a science.It helped me recognize the nuance that is involved in making keen medical observations.
[P]erspective-taking; things can viewed from multiple angles, offering new methods/plans; discussion in large group settings can elucidate new points of view -every[one] observes things in a slightly different manner, additionally new perspectives can be incredibly impactful.
Viewing a piece of art or a patient from different perspectives.Different perspectives enhances observational skills.You see things you otherwise would not have seen.This can translate into helping the patient in new ways.
I see patients with more empathy and pay more attention to them as a whole person-focusing more on their body language and facial expressions

Physicians/Others
I think the course helped me pay closer attention to detail in my professional life and when looking at art.I do a lot of listening professionally in my work, and it has helped me augment my attentiveness to emotional cues.
Looking at colors and lighting and facial expressions.It awakened my visual perception.
Reminding myself to be more aware of art not just "formal art" but art in everyday life.To be more observant, and inclusive in my studies.
I now look for pathologies in artwork, where I never did this before.I am more aware of how the artist's perceptions can be tainted by disease.
It made me become a more careful and sensitive observer.
I can better appreciate that my observational powers are limited by my experiences but can be broadened.

Medical Student
The course definitely presented a more humanistic view of medicine than our traditional medical school courses.By analyzing works done by patients or about patients, I felt that I had the opportunity to concretely see how physicians can have an impact on peoples' everyday lives.

Physicians/Others
I feel more grounded in history--being able to see disease and the human experience from the eye of a medically trained professional even though it was art made by someone who is not medically trained.
Seeing historical paintings of the changing styles and mores of the medical field gave me perspective and reflection.I think I am more aware of the human side of being a physician that is timeless in spite of differences in dress and posture.
Enhanced appreciation of human beings.
It is a wonderful course because it bridges the Arts and the Sciences/Medicine making it truly unique, giving a novel paradigm to what was CP Snow division of cultures.As physicians, we need to know rigorous science, proper diagnosis, analytical skills to evaluate study results of novel therapies but there is also a tremendous amount of human aspects of life/living, suffering and death and its metaphysical aspects.A bridged dialogue as this course offers is uniquely important for medical education.

Medical Students
Art history has always been my side passion, my "coulda shoulda woulda" of sorts, we all have one of those other than medicine, so I think that when I heard this course was an offering I was so pleasantly overjoyed, it showed me that there was a way for me to not totally give up that passion down the line.
This course has given me an appreciation for paintings and how much goes into making them.
I find myself deliberately slowing down in museums and my own personal art collection to take in more of the work.
Yes, I definitely consider art through a more medical lens now and I think this has really added depth to the way I approach art.It feels like solving a puzzle.
The Collers did a really nice job demonstrating how their respective backgrounds inform the way they consume art, which made an impression on me! Art as lens to view the human condition and illness.
There was a particular session on curating art for hospital settings.I now see works that fall into two categories: art that depicts medical conditions (of the subjects), and art that is affected by medical conditions (of the artist).
Absolutely--made me more aware of observing details within a painting, rather than looking at a work of art as a whole I actually have spent more time in exhibits [o]n each painting and looking into its historical aspects and temporal context in more detail since I attended this course.
[P]ay more attention to the work of art and less time reading about the work.

Medical Students
It made me want to learn more about the history of medicine.
Certainly!I had never really given much thought to the history of medicine, but this course really highlighted just how much the history of medicine is intertwined with the history of art.
I did not know much about the history of medicine prior to this course.Understanding the history of our day-to-day work can only further inform the present and our current roles/responsibilities.It is also humbling to know where we have come from The class was a fun exploration into the history of medicine, and made me want to read more.
Learned about history of medicine from the lens of art -something I had not done before.
I think interacting firsthand with the history of medicine and seeing books centuries old and learning from them was powerful.I went back to the NYAM [New York Academy of Medicine] after this experience as I was so inspired.I also loved learning about the architecture during our tour as well and started appreciating other similar forms around the city.
Yes, it made me become more interested; recently, it has made me curious about better understanding the historical foundations of some racist aspects of the medical profession.
Yes, even just exploring the rare book room with the Drs.Coller at the NYAM awoke in me an appreciation for how far medicine has come... and how even still, we know astonishingly little about how the human body works and how we can improve it.
I appreciate the history of medicine to a greater extent.

Physicians/Others
I learned how much the history of medicine is relevant to how we practice medicine today.
I am more curious on the history of certain illnesses and perceptions of illness.I think I had this curiosity before the course but that the course increased my curiosity.
The images stay in my memory better than any historical text about history of medicine.But it also made me curious to read texts about history of art and medicine Absolutely--Barry's historical discussions were truly fascinating and detailed--covering some areas about which I was less familiar.The interface of Bobbi's discussions of the art with Barry's medical focus was superb and made the course exceptional.
Absolutely!It is so important to understand the historical aspects of medical discoveries and societal aspects of illnesses and pandemics.This is truly highlighted in the course.
The intersection of the arts and sciences has always been intriguing to me, especially through a historical lens.In 2021, history and historical context is now more important than ever in helping us understand the "why" of so much that is occurring.
[V]ery humbling to think about the limited tools at the disposition of prior generations of physicians.
It was fascinating how the history of medicine was documented through art.It is astonishing to see practices we now know to be ineffective, glorified on canvas.
87% (13/15) of the medical students responded that the course had an impact on how they view works of art compared to 95% (19/20) of the Physicians/Others.87% (13/15) of the medical students responded that the course had an impact on their appreciation of the history of medicine compared to 90% (18/20) of the Physicians/Others.80% (12/15) of the medical students responded that the course had an impact on their observational skills, the same percentage as the Physicians/Others (16/20).
53% (8/15) of the medical students responded that the course sensitized them to the patient's perspective of illness compared to 65% (13/20) of the Physicians/Others.40% (6/15) of the medical students responded that the course had an impact on how they viewed their role as a physician compared to 65% (13/20) of the Physicians/Others.
Comparing those who took the course before 2016 to those who took the course in 2016 or after, there were no obvious differences in the responses to the questions by medical students or Physicians/Others based on whether they took the course before 2016 or in 2016 or after (Table 3).

Discussion
One of the recognized limitations of studies of the impact of introducing the humanities in medical school curricula is the limited data on the long-term impact of such courses.Our data indicate that our course has had a long-lasting impact on at least a significant minority of participants, whether they were medical students, faculty, physicians in training, or staff members when they took the course.Our study is limited by the modest survey response rate and the likelihood that those who responded may have been motivated to respond because the course did have an impact on them.Other factors that may have contributed to the low response rate was its deployment by email to the last known email address of the students, the fact that our list included students who may not have attended more than a few sessions, and general survey fatigue by busy physicians.Medical students who took the course before 2016 had the lowest response rate, which may be attributed to the course having less of a lasting impact on them, their being in a phase of their career and family responsibilities where time is especially limited, and/or their contact information being less reliable because of the longer time since their graduation.
It is gratifying that 97% of those who did respond indicated that they still do think about the course and that their free text comments indicate that many of them feel that the course had a meaningful impact on how they think about and practice observation, and their appreciation of art and medical history.
There was a clear gradient of impact, with very large majorities noting the impact on viewing art, appreciating medical history, and observation, a smaller majority noting the impact on being sensitized to the patient's experience, and with a bare majority noting an impact on their role as a physician.In general, the responses were similar between those who took the course as medical students and those who were already physicians, and there were no obvious differences in responses based on whether the respondent took the course more than or fewer than 5 years before completing the survey.
The past decade has witnessed an increasingly intense focus on physician burnout and a recognition of the importance of promoting physician wellness [18][19][20]

Amanda Swain
Department of Family Medicine & Community Health, University of Pennsylvania, Philadelphia, USA I really value attempting research on the longitudinal impact of medical humanities education.I agree with the authors that this is sorely needed.

I have a few comments/suggestions below for the authors:
1.I recommend an editor review the piece.There are many run-on sentences that make sections hard to read.
2. The very first sentence is misleading.Medical humanities education is not a recent trend, it has been used in US medical education for 20+ years and much longer in European medical schools.I suggest this sentence is adjusted to reflect this fact.
3. I think the questionnaire to alumni would have benefited from a Likert scale.The yes/no questions limit the utility of the information collected.I realize this data has already been collected, but in a methods section it would be helpful to discuss why they decided on yes/no vs something more detailed.I think this deficit could have been made up for by a content analysis of the answers (if there had been more of them).
4. If the authors are going to comment on burnout it makes more sense to do so earlier in the article and then circle back to it in the discussion section.
5. Curious if the authors plan to use any of the data collected for this article to make changes to their current course.

Is the work clearly and accurately presented and does it cite the current literature?
Partly

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes Are the conclusions drawn adequately supported by the results?Yes

Is the case presented with sufficient detail to be useful for teaching or other practitioners? No
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Faculty involved in medical humanities curriculum, elective planning and research.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Author Response 16 Aug 2024

Barry Coller
We thank Dr. Swain for the careful review and appreciate her identifying the need for data on the longitudinal impact of medical humanities as a strength of our manuscript.I have a few comments/suggestions below for the authors: Reviewer's Comment: I recommend an editor review the piece.There are many runon sentences that make sections hard to read.

Response:
We would be pleased to review any sentences that Dr. Swain or an editor thinks needs revision. 1.

Reviewer's Comment:
The very first sentence is misleading.Medical humanities education is not a recent trend, it has been used in US medical education for 20+ years and much longer in European medical schools.I suggest this sentence is adjusted to reflect this fact.
Response: We thank Dr. Swain for the suggestion.We have modified the sentence accordingly.It now reads as indicated below.Calls for integration of the humanities into medical education go back at least to the 1940s, but judging by PubMed citations, there has been a dramatic increase in interest and scholarship in this area during the past two decades.

2.
Reviewer's Comment: I think the questionnaire to alumni would have benefited 3.
from a Likert scale.The yes/no questions limit the utility of the information collected.I realize this data has already been collected, but in a methods section it would be helpful to discuss why they decided on yes/no vs something more detailed.I think this deficit could have been made up for by a content analysis of the answers (if there had been more of them).
Response: Dr. Swain makes a good point.In reflecting on our choice of yes/no answers, we believe it derived from our sense that most of the answers to the questions would be binary, such as whether they still think about the course.We acknowledge that some of the others may have lent themselves to Likert scale assessment and will consider this for future research.
Reviewer's Comment: If the authors are going to comment on burnout it makes more sense to do so earlier in the article and then circle back to it in the discussion section.

Response:
We thank the reviewer for the suggestion, and we have now added the sentence below in the Introduction.Although not one of our stated goals, in the course of our analysis we noted that a number of respondent comments touched on the issue of physician burnout and wellness, a subject that has been a focus of recent attention, and so we briefly discuss the potential of courses like ours to contribute to physician wellness.

4.
Reviewer's Comment: Curious if the authors plan to use any of the data collected for this article to make changes to their current course.
Response: Based on the comments related to wellness, we are thinking about how to modify our course or create a related course that focuses more on this important issue.We now plan to ask specifically about wellness in our course survey.

5.
Competing Interests: No competing interests were disclosed.

Ian Sabroe
The University of Sheffield, Sheffield, England, UK I reviewed the paper of Coller et al with interest.The authors have been running a longstanding elective course which they describe as examining the intersection of art and medical history, with clear goals identified around observation skills, respectful discussion, the experience of illness, and understanding of medical history.To their credit, they wished to evaluate the impact of this course and have done so by means of a questionnaire.I applaud the desire to evaluate their course, and am interested to read the results.I wish the authors had not used leading questions in their survey to the extent that they have.Although the questions are open and inviting comment, they do have a leading nature by directing the respondents to consider the course and then their observational skills, physician role, etc.The questions could have focused more on lasting aspects without tying them to specific parameters, in order to generate a more open, unstructured reflection.I am also concerned about one line in the methods, where 'students who answered yes' to a question were invited to add free text to explain their answers.If people answered 'no', their reflections on the course and question would be equally valid and useful or important to capture.
Regarding the data generated, as the authors note the numbers of responses are relatively small.Surveys were sent to 167 students (which would appear to be all/most of those taking the course over 10 years) and responses were from 35 students.The limitations of this small sample size are clearly acknowledged, and the limitations of the study appropriately discussed.
Of those who responded, there are warm responses towards the aims of the course and positive recollections of it presented.(I note again that the survey did have somewhat leading questions, which provide a potential bias.)A series of 'selected quotes' are presented, without being clear how such quotes were chosen.Whilst it's clear that the course had a very positive impact on some respondents, there's a risk of selection bias in the choice of quotes presented in the main paper.
The discussion of the data generated acknowledge the positive results gained and some of the limitations of the study.It would perhaps also be useful to set the discussion of this course a bit more in the overall offering of the School, and the importance it attaches to humanities-based options.Students who took this module may have also been influenced in how they viewed this particular module by participation in other courses, e.g. in narrative medicine.It's too late to explore whether there were any mutual interdependencies/reinforcements between courses in the survey, but briefly discussing the School's overall humanities offerings and attitudes to them might add value.
A minor point, but in the supplemental materials, one link (reading and misreading faces) needs a proper link direct to the source material.
As a point of discussion, the final paragraph of the discussion causes me to wonder how we present the importance and benefit of such courses.I cannot conceive of a future in which the practice of medicine will be easy.It will always be challenging, acutely and over a lifetime.I am all in favour of all wellness programmes.I support approaches that can positively impact on the lifetime stress of our career, as well as those that offer diverse ways of learning about illness.I think we should be incorporating humanities-based learning, knowledge and wisdom into training and practice as part of a standard to support clinician learning, practice, identity formation and wellbeing, for the benefits of our patients, societies, and ourselves.But… I believe the work of addressing clinician distress and burn-out requires deep reforms of working practice, clinician support etc, and that the work of creating more sustainable, survivable careers is to some degree an independent (and great) problem.

Is the case's background and context in sufficient detail? Yes
Is the work clearly and accurately presented and does it cite the current literature?Partly

If applicable, is the statistical analysis and its interpretation appropriate? Partly
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Partly
Is the case presented with sufficient detail to be useful for teaching or other practitioners?Yes Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Medical humanities, biomedical science, respiratory medicine I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
parameters in order to generate more open, unstructured reflection."We agree that an open request for "lasting effects" would allow for broad reflection, but we were specifically interested in knowing whether we achieved our goals and so we tried to obtain this information by asking questions that we thought were presented in a neutral fashion.We balanced this by providing respondents an opportunity via open text to express unstructured thoughts and reflections.We also were concerned that fully unstructured questions would present significant analytical challenges.
Reviewer's comment: I am also concerned about one line in the methods, where 'students who answered yes' to a question were invited to add free text to explain their answers.If people answered 'no', their reflections on the course and question would be equally valid and useful or important to capture.
Response: We appreciate Dr. Sabroe's comment, but we didn't think that, for example, people who do not still think about the course would be interested in explaining why they no longer think about it.In addition, we did provide an opportunity for free text about anything they would like to add.
Regarding the data generated, as the authors note the numbers of responses are relatively small.Surveys were sent to 167 students (which would appear to be all/most of those taking the course over 10 years) and responses were from 35 students.The limitations of this small sample size are clearly acknowledged, and the limitations of the study appropriately discussed.We, of course, would also have preferred a high response rate, but we felt that the 35 responses provided sufficiently valuable information to justify reporting our results.We appreciate Dr. Sabroe's acknowledgement that we were transparent in reporting the response rate and noting the limitations of our study.
Reviewer's comment: Of those who responded, there are warm responses towards the aims of the course and positive recollections of it presented.(I note again that the survey did have somewhat leading questions, which provide a potential bias.)A series of 'selected quotes' are presented, without being clear how such quotes were chosen.Whilst it's clear that the course had a very positive impact on some respondents, there's a risk of selection bias in the choice of quotes presented in the main paper.

Response:
The only "selection" of the quotes was based on whether the respondent did or did not give permission for the publication of their de-identified comment.The table and spreadsheet uploaded to Zenodo contains all of the responses that the respondents agreed to allow to be published.The following sentence has now been added under "Data analysis" describing the compilation of the statements.All free text statements added by respondents who agreed to allow their responses to be published were compiled and are reported in Table 4.The discussion of the data generated acknowledge the positive results gained and some of the limitations of the study.
Reviewer's comment: It would perhaps also be useful to set the discussion of this course a bit more in the overall offering of the School, and the importance it attaches to humanitiesbased options.Students who took this module may have also been influenced in how they viewed this particular module by participation in other courses, e.g. in narrative medicine.
It's too late to explore whether there were any mutual interdependencies/reinforcements between courses in the survey, but briefly discussing the School's overall humanities offerings and attitudes to them might add value.

Response:
We have now added the paragraph below into the Discussion in response to Dr. Sabroe's suggestion.We did not assess mutual interdependence/reinforcements between courses with questions in the survey, in part because we did not consider this possibility, but also because we wanted to keep survey as short and simple as possible so as to increase the response rate while trying to obtain the most information.The Icahn School of Medicine has been a pioneer in integrating Humanities in Medicine through a rich set of offerings to medical students.The school also created a "Humanities and Medicine" admissions process under Dean Nathan Kase's leadership in 1987 to better enable students with a strong interest in the humanities to become physicians.Currently, the humanities offerings are under the auspices of the Academy for Medicine & the Humanities.In addition to the Pulse of Art, the Academy offers a number of courses in creative writing, music, history, the social sciences, and the visual arts.The Academy also sponsors mentored research opportunities, which include students creating courses for other students.The school also allows students to fulfill their research graduation requirement by participating in a Medical Humanities Scholars Track.
Reviewer's comment: A minor point, but in the supplemental materials, one link (reading and misreading faces) needs a proper link direct to the source material.
Response: Thank you for letting us know.We have fixed the link.
As a point of discussion, the final paragraph of the discussion causes me to wonder how we present the importance and benefit of such courses.
Reviewer's comment: I cannot conceive of a future in which the practice of medicine will be easy.It will always be challenging, acutely and over a lifetime.I am all in favour of all wellness programmes.I support approaches that can positively impact on the lifetime stress of our career, as well as those that offer diverse ways of learning about illness.I think we should be incorporating humanities-based learning, knowledge and wisdom into training and practice as part of a standard to support clinician learning, practice, identity formation and wellbeing, for the benefits of our patients, societies, and ourselves.But… I believe the work of addressing clinician distress and burn-out requires deep reforms of working practice, clinician support etc, and that the work of creating more sustainable, survivable careers is to some degree an independent (and great) problem.
Response: We share Dr. Sabroe's view that clinical distresses and burn-out requires structural reforms of many aspects of medical training and practice, and that much of this is independent of courses like ours.At the same time, even though we did not explicitly provide questions about burn-out or wellness, several spontaneous comments indicated that at least for some of the respondents, the time in our course provided an antidote to the stresses of their medical responsibilities, and we were struck by similar comments about humanities courses in the literature.Thus, since we recognize the need for a holistic approach to physician well-being, we think it worth exploring how courses like ours can contribute to that goal.

Sapienza University of Rome, Rome, Italy
It is an interesting study.It would be interesting to know if at the end of the courses a qualitative or quantitative questionnaire was administered regarding the impact on observation skills, empathy or well-being.It would also be interesting to know how the artworks with which to activate the discussion of participant are chosen and what type of method is applied both in the classroom and in the museum.I confirm that the paper is very important in the study of Humanities in Medical Education and that is of an acceptable scientific standard with minor revisions for a indexed.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Is the case presented with sufficient detail to be useful for teaching or other practitioners?Partly Competing Interests: No competing interests were disclosed.
Reviewer Expertise: My area of expertice and research is the application of the Visual Thinking Strategies method and other artistic practices for the training of medical and nursing students and continuing education in the healthcare area for developing skills and limiting stressof personell I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Author Response 16 Aug 2024

Barry Coller
We thank Dr. Ferrara for the careful review, and we are pleased that he judges our study to be interesting and very important in the study of Humanities in Medical Education.We offer the following response to his comments.It is an interesting study.
Reviewer's comment: It would be interesting to know if at the end of the courses a qualitative or quantitative questionnaire was administered regarding the impact on observation skills, empathy or well-being.
Response: After each session of the course, we request that students provide responses to a series of questions related to that session, but we also encourage general comments and suggestions.In addition, at the end of the course, we request that students complete a survey related to the course as a whole.In the latter, we ask the following questions."With a scoring system of 1-5, with 5 being the best, how would you rate the success of the course in achieving each of the following goals: Encourage careful observation, 1.
Provide an understanding of some of the key milestones in medical history, 2.
Encourage awareness of, and sensitivity to, the impact of illness on patients and their families.

3.
Reviewer's comment: " We do not specifically use the term empathy, but we think that question 3 relates to empathy, and we prefer to avoid the term empathy itself because of the heavy emotional overlay associated with this word.We have not yet asked about wellbeing, but in response to the reviewer's question, we will add a question related to wellbeing.
Response: It would also be interesting to know how the artworks with which to activate the discussion of participant are chosen and what type of method is applied both in the classroom and in the museum.
The art works are selected primarily based on both their art historical and medical historical significance, either directly or indirectly.These representational works are supplemented with other works of art to demonstrate the power and variety of art, including examples of abstraction, photography, and sculpture that reinforce the key theme of the session.In the classroom, the emphasis is encouraging the students to observe the works in silence for several minutes and then begin to discuss what they observed and their reaction to the work as a whole, in the context of the topic.This approach incorporates key elements of Visual Thinking Strategies.
The Guggenheim visits are led by a highly respected museum educator, Sharon Vatsky, who has extensive experience in developing and leading educational activities.She has written two books on this topic, Museum Gallery Activities: A Handbook (American Alliance of Museums) and Interactive Museum Tours: A Guide to In-Person and Virtual Experiences.She engages the students in first observing and then using a series of exercises to elicit their responses, including passing papers around from person to person, in which each person in turn writes their response to a series of questions, followed by a group read-back.
The New York Academy of Medicine Rare Book Room Librarian, Arlene Shaner, displays a series of books that relate to the course or to the individual interests of the students, providing a historical context and comparing the works to others published at the same time.She emphasizes how the works also fit into the history of book printing and publishing, and figure production.

1 .
Sessions Taught by Bobbi and Barry Coller -Observation in Medicine and Art -Images of Illness -Picturing Pandemic Diseases -Skin Deep: Dermatology in Art -Reading and Misreading Faces -The Gross Clinic and the Ascendancy of American Science and Medicine in the 19 th Century -The Vaccine Wars: Learning from Smallpox 2. Guest Lecturers (selections in different years depending on lecturer availability) -Diane Brown, RxArt -Anne Garner, Former Curator of Rare Books and Manuscripts, New York Academy of Medicine -Rick Giudotti, Positive Exposure -Hope Grayson, Painter -Bert Hansen, Professor of the History of Science at Baruch College in New York -Alexandra Horowitz, Adjunct Associate Professor at Barnard College -Asti Hustvedt, Independent Scholar / Writer -Joe Lovett, Lovett Stories and Strategies -Arlene Shaner, New York Academy of Medicine Historical Collections Librarian -Sharon Vatsky, Former Director School Programs, Solomon R. Guggenheim Museum -Christina Yang, Former Director Adult Programs, Solomon R. Guggenheim Museum 3. Visits to Other Institutions -The Solomon R. Guggenheim Museum -The New York Academy of Medicine, Rare Book Reading Room Table 2. Survey questions.When you took the Pulse of Art Course, were you a: Medical student, Faculty member, or Other?Did you take the course before 2016 or in 2016 or thereafter?Do you ever think about the course?If yes, what triggers your memory?Do you think the course had an impact on your observational skills?If so, how?Do you think the course had an effect on how you view your role as a physician?If so, how?Do you think the course had an effect on how you view works of art?If so, how?Do you think the course had an impact on your appreciation of the history of medicine?If so, how?Do you think the course sensitized you to the patient's perspective of illness?If so, how?

Reviewer Report 09
August 2024 https://doi.org/10.21956/mep.21537.r38112© 2024 Sabroe I.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

:
No competing interests were disclosed.Reviewer Report 07 August 2024 https://doi.org/10.21956/mep.21537.r38117© 2024 Ferrara V.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Table 4A . Do you ever think about the course? / What triggers your memory?
Makes me think longer about the intentions of the artist and symbols that might be in the art work I view art in a systematic way, using the skills learned in the class to "take in" what I am appreciating, think why the artists did what they did, look for what may be missing, etc.I pay more attention to detail in art, want to know the historical context of the painting or art work, and am curious [about] the medical illness if depicted in the piece of art.Well you know the first second of looking at a patient sets the tone of the visit.The same when you approach art.[Y}ou see it first, [t]hen you analyze.
Through this session, I began to appreciate how art can foster a welcoming and less stressful environment in the hospital.It taught me to pay attention to details that I previously ignored I now take my time looking at each piece of artwork instead of rushing through a museumPhysicians/Others

Open Peer Review Current Peer Review Status: Version 1
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
21Although we did not specifically ask a question related to physician wellness in the survey, we have performed surveys each year after each class and at the end of the course.One of the spontaneous comments from a student and another from a junior faculty member are very similar to that of the medical student quoted above.21.We hope that our course and others like it can make a contribution to this vital need and that future research can define the key elements that correlate with having a positive impact on medical student and health worker wellness.https://doi.org/10.21956/mep.21537.r38111©2024 Swain A.